CHSS –1/260-A

(in Quadruplicate)

BHABHA ATOMIC RESEARCH CENTRE

(Contributory Health Service Scheme)

APPLICATION FOR CHSS CARD

(INITIAL REGISTRATION)

PART I : To be filled in by the Applicant

Note :

  1. Membership of CHSS is obligatory for all employees residing in Mumbai, Navi Mumbai & Thane.

2. Married/widowed/divorced or legally separated daughters of an employee, though dependent, on the employee, are not eligible for benefits under CHSS. In the case of adopted children, legally adopted sons and daughters are eligible for benefits under CHSS.

3.Separate applications have to be made for registration of parents (or parents-in-law in the case of female employees) and dependents [Form No. CHSS/4(271)].

4.Spouse of the Govt. Servant and the two children who are wholly dependent are eligible for the benefits under CHSS. Additional children shall be registered by payment of additional contribution.

First Name/ Middle Name/ Last Name / Designation / Division/Section / Unit
Shri/Smt/Kum/Dr./
Employee No. / Comp. Code No. / Telephone No.
Office : / Residence :
Temporary No. if any given by BARC Hosp. for medical / Gender – Male/ Female / Marital Status / Blood Group
Date of appt. : / Residential Address (Pin code Compulsory)
Basic Pay:
Rs. D.P. Rs. / Bldg Name -
Flat/ House No.: Area/ Street -
City :-
Email ID PIN CODE

PARTICULARS OF FAMILY MEMBERS

SI. No. / Name (in block capital) / Relationship / Date of birth with certificate / Occupation / CHSS No. (if any) / Date of admission to CHSS
1. / Self / Govt service
2. / Spouse / Housewife/ employed
3.
4.
5.
6.

Whether the spouse is eligible for medical benefits from any other source ?

No. / Yes from

(Spouse should not be availing medical facility from employer. Certificate to this effect should be produced. Also submit 2 photographs each of spouse/ child)

I undertake to inform CHSS office about any change which may affect eligibility for CHSS benefits in respect of my family members included above.

I declare that I have read the above instructions and the information furnished above is true and correct.

Date : ______

Signature of Applicant

CHSS 1/260-A

Part II : For use in Recruitment Section

Ref. :Date :

Forwarded

______

Assistant Personnel Officer

To,

APO (CHSS)

Part II : For use in CHSS Office, BARC Hosp.

Registration completed

CHSS No. / Dispensary

______

Assistant Personnel Officer

BARC Hosp.

Date

To :

  1. APO/Admn. Officer, BARC/ ______(Unit)

2.Accounts Officer ( ) BARC/ ______(Unit)

3.M.O.In-charge, ______Dispensary